The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?

Document findings

Determine whether the patient can count fingers

Obtain a tumbling E chart to assess visual acuity

Complete an internal eye exam .

Answer and Explanation

The Correct Answer is B

Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen

chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.

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Correct Answer is A

Explanation

Choice A rationale
For a client with Parkinson’s disease who has difficulty swallowing or chewing due to muscle rigidity, semi-solid food with thick liquids can be easier to swallow and reduce the risk of choking19.
Choice B rationale
Minced foods and fluid restriction may not provide the necessary nutrients and hydration for a client with Parkinson’s disease19.
Choice C rationale
A low-residue diet, which is low in fiber, may not be appropriate for a client with Parkinson’s disease, as constipation is a common symptom of the disease and fiber can help alleviate this19.
Choice D rationale
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. It is typically reserved for clients who cannot or should not get their nutrition through eating19.

A. Support the right arm with a sling or pillow to prevent shoulder dislocation. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Place the wheelchair on the client’s left side when transferring him into a wheelchair. D. Provide close supervision because of the client’s impulsiveness and poor judgment.

Correct Answer is D

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing the breath sounds of a client with Parkinson’s disease, a nurse hears adventitious sounds. How should the client’s nutritional needs be met?

Correct Answer is A

Explanation

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?